Transactions and Code Sets The Unfinished Business

2. Transactions and Code SetsThe Unfinished Business Telecommunication and HIPAA Issues, Concerns, Recommendations Chris Stahlecker Christine.Stahlecker@ctghs.com March 13, 2002

3. Telecommunication and HIPAA The HIPAA regulations are silent on standardizing telecommunication methods. Discussion points • Current State • Desired State • Gaps to fill • Recommendations

4. Clearing Houses Clearing Houses Clearing Houses Clearing Houses Providers Clearing Houses Clearing Houses Payers Practice Management, Scheduling, Billing, Patient Accounts Systems Claims Adjudication Systems Service Vendors Internet TPA* *Trading Partner Agreement and/or EDI Enrollment Form Current State Overview

5. Telecomm IssuesCurrent State • HIPAA requires batch file transfer. • HIPAA does not specify any standard telecomm protocol. • Payers have selected the current, in-use capabilities, interactive and batch. • Payers have been silent on protocol changes for existing or new transactions. • Medicare says ‘no’ to using the open internet.

6. Telecomm IssuesDesired State • Convenience of Open EDI. • Security and speed of dedicated line. • Cost-savings of the internet. • Seamless applications integration.

7. Clearing Houses Clearing Houses Clearing Houses Clearing Houses Providers Clearing Houses Clearing Houses Payers Practice Management, Scheduling, Billing, Patient Accounts Systems Claims Adjudication Systems Open EDI over the internet CPP/A* Service Vendors CPP/A* *Collaborative Protocol Profile/Agreement; Certificate Authority and Digital Signature assumed. Industry TrendDesired State Overview

8. Getting Back To The Business Office...

9. Telecomm IssuesGaps To Fill Practical Perspective: • Providers’ internet access is not through Practice Management (PM) products. • PM and Service Vendors are not offering the new transactions. • Providers do not have resources/staff to implement anything beyond what their PM vendor supplies.

10. Telecomm IssuesGaps To Fill Practical Perspective: • Methods to access payers’ new transactions are inconsistent. • Trading Partner and/or EDI Agreements inconsistently used/required. • Providers may need to receive inquiries or requests for information and therefore need appropriate security.

11. Telecomm IssuesGaps To Fill Practical Perspective: • Payers’ network services are sized for claim and remittance. • Consider transaction volume increase. • Consider interactive transaction increase. • Payers security systems often use logon and password. Consider implications of time-out, password re-sets, providers’ employee turnover, role-based access. • Payers security often based on Data Set Names for each transaction. Where are the requirements?

12. Telecomm IssuesGaps To Fill Technical Perspective: • Establish an inventory of connectivity and transport protocols currently used. • Define the use, if any, of Identifiers as parameters for Routing. • Define ‘acceptable’ methods for Routing: • Envelope (ISA/IEA) • Transaction (Table 1) data manipulation • Other • Define the mechanism for distributing this information to Covered Entities

13. Recommendations • Focus on mission critical transactions. • Follow the WEDI SNIP Transaction Sequencing proposal version 2. • Focus on batch transactions over existing networks using Payers’ defined security. • Consider using a Clearinghouse where direct point-to-point is not offered. • Sectors of the industry are unaware of the complexities and may have omissions in their test plans. Check this as you prepare your Extension Request.

14. Recommendations • Pay attention to emerging technologies and industry leaders (subscribe to listservs). • Include internet access for Providers’ business office personnel in your strategic plan. • Include internet access for Provider and Payer medical records’ personnel in your strategic plan. • Aggressively persuade PM and Service Vendors to include the new transactions. • Plan to monitor/manage the exceptions.

15. Recommendations Participate or at least monitor activities of: The WEDI/AFEHCT Health Care Communications Interoperability Work Group Http://SNIP.WEDI.ORG/listserv/ Under Transactions, select Routing and Sign Me Up!

16. Useful Links • http://snip.wedi.org/ • subscribe to routing@wedi.org • http://www.wedi.org/ • http://www.afehct.org/security.asp • http://www.healthkey.org/library.htm • http://www.oasis-open.org/committees/ebxml-cppa/ documents/presentations/index.shtml • download or read: ebXML version 1.0 CPP-CPA.pdf • http://lists.oasis-open.org/archives/ebxml-cppa/ • http://lists.ebxml.org/archives/ebxml-dev • http://www.novannet.com/wedi/